Introduction

There is an increased awareness of the need for a structured approach to be taken to the diagnosis and management of asthma/COPD overlap. The joint Global Initiative for Asthma/Global Initiative for Chronic Obstructive Lung Disease (GINA/GOLD) guidelines from 2015 go some way to recognising the condition and the challenges of appropriate management. In this case study, based on these and other guidelines, we discuss the case of Sami whose asthma symptoms are causing problems.

Sami is 49 years old and has had asthma since childhood. He is currently managed with a low dose inhaled corticosteroid (400mcg total daily dose equivalent). He has been a lifelong smoker, with a 35 pack year history. He currently smokes 10 standard cigarettes a day, which he supplements with ‘vaping’.

Section 1 Sami presents for his annual review and says that he feels his asthma treatment is not working as well these days and requests ‘something stronger’. He has had a chronic cough for several months and produces a few teaspoonfuls of sputum every morning. He is also more breathless carrying out his day to day activities and is using his short acting bronchodilator most days. His personalised asthma action plan tells him that this indicates poor asthma control. You decide to carry out post-bronchodilator spirometry which shows an FEV₁/FVC ratio of 56%, an FEV₁ of 65% predicted and a normal FVC.

What does this test result tell you?

He has moderate COPD

He has moderate irreversible airflow obstruction

He has mild reversible airflow obstruction

He has mild COPD

indicates the correct answers for this question

Explanation

Section 1 Sami presents for his annual review and says that he feels his asthma treatment is not working as well these days and requests ‘something stronger’. He has had a chronic cough for several months and produces a few teaspoonfuls of sputum every morning. He is also more breathless carrying out his day to day activities and is using his short acting bronchodilator most days. His personalised asthma action plan tells him that this indicates poor asthma control. You decide to carry out post-bronchodilator spirometry which shows an FEV₁/FVC ratio of 56%, an FEV₁ of 65% predicted and a normal FVC.

Answer B is correct. Spirometry tells you what the lung function looks like but cannot give an actual diagnosis as this will be based on the history, with the spirometry being one part of the diagnostic process. According to NICE (2010) this spirometry indicates moderate irreversible airflow obstruction.

Section 2 You explain to Sami that his lung function shows some impairment despite his current treatment.

Explanation

Section 2 You explain to Sami that his lung function shows some impairment despite his current treatment.

Answer D is correct. Sami has symptoms and spirometry which are compatible with asthma/COPD overlap but before the diagnosis is made, other possibilities should be considered of other before altering his treatment. A greater focus on history taking may help to identify features that are more suggestive of, for example, lung cancer, rather than asthma/COPD overlap. A review of his history and previous asthma diagnosis should be carried out as well as a chest X-ray, bloods or even a scan based on the history obtained (GINA/GOLD 2015).

Section 3 Following a full assessment and further investigations, Sami been diagnosed with asthma/COPD overlap. He has a history of asthma which is controlled as far as possible with his current treatment. However, he also has persistent airflow obstruction, probably due to his smoking history, leaving him with an MRC dyspnoea score of 3 (equal to a modified MRC score of 2).

Using the GOLD algorithm from the COPD guidelines (GOLD 2017), into which category (A B C or D) does Sami fit?

A

B

C

D

indicates the correct answers for this question

Explanation

Section 3 Following a full assessment and further investigations, Sami been diagnosed with asthma/COPD overlap. He has a history of asthma which is controlled as far as possible with his current treatment. However, he also has persistent airflow obstruction, probably due to his smoking history, leaving him with an MRC dyspnoea score of 3 (equal to a modified MRC score of 2).

Using the GOLD (2017) ABCD algorithm, Sami fits into category B based on his modified MRC score of 2 with no history of exacerbations.

Section 4 Following a full assessment and further investigations, Sami been diagnosed with asthma/COPD overlap. He has a history of asthma which is controlled as far as possible with his current treatment. However, he also has persistent airflow obstruction, probably due to his smoking history, leaving him with an MRC dyspnoea score of 3 (equal to a modified MRC score of 2).

Based on GOLD (2017) guidance for COPD, which treatment option is recommended for category B patients?

A long acting bronchodilator

An ICS/LABA

Salbutamol as required up to 4 times a day

A high dose inhaled corticosteroid

indicates the correct answers for this question

Explanation

Section 4 Following a full assessment and further investigations, Sami been diagnosed with asthma/COPD overlap. He has a history of asthma which is controlled as far as possible with his current treatment. However, he also has persistent airflow obstruction, probably due to his smoking history, leaving him with an MRC dyspnoea score of 3 (equal to a modified MRC score of 2).

Answer A is correct. GOLD states that patients in category B should be offered a long acting bronchodilator. The guidelines suggest that either a LABA or a long acting muscarinic antagonist (LAMA) will be appropriate for this class of patient. If either alone is inadequate, a dual bronchodilator should be considered (GOLD 2017). However, it is important to remember that these guidelines are for COPD only. Any reversible airways disease should be treated as per the asthma guidelines (British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) 2016). People with asthma/COPD overlap will need treatment which recognises both conditions (GINA/GOLD 2015).

Section 5 Sami has asthma/COPD overlap. Despite his current treatment with a low dose ICS, he is still breathless on exertion most days and is needing to use his salbutamol at least twice a day. His oxygen saturations are 97%.

Which one of these treatment options most effectively meets the needs of a patient who presents like Sami?

A high dose ICS/LABA

A dual bronchodilator

A long acting bronchodilator – LABA or LAMA

A low dose ICS/LABA

indicates the correct answers for this question

Explanation

Section 5 Sami has asthma/COPD overlap. Despite his current treatment with a low dose ICS, he is still breathless on exertion most days and is needing to use his salbutamol at least twice a day. His oxygen saturations are 97%.

Answer D is correct. Sami needs to continue to treat his asthma with the low dose ICS but also needs long acting bronchodilation for his symptoms of breathlessness caused by his irreversible airflow obstruction. This could be with a LABA or a LAMA. On that basis it is appropriate to offer either a low dose ICS/LABA or to continue his current asthma therapy and add in a LAMA as a separate inhaler to treat the COPD element of his condition (GINA/GOLD 2015).

Section 6 Sami has asthma/COPD overlap. Despite his current treatment with a low dose ICS, he is still breathless on exertion most days and is needing to use his salbutamol at least twice a day. His oxygen saturations are 97%.

What else should form part of Sami’s package of care following his diagnosis of asthma/COPD overlap?

Smoking cessation and pulmonary rehabilitation

Smoking cessation and end of life planning

Pulmonary rehabilitation

Oxygen therapy and smoking cessation

indicates the correct answers for this question

Explanation

Section 6 Sami has asthma/COPD overlap. Despite his current treatment with a low dose ICS, he is still breathless on exertion most days and is needing to use his salbutamol at least twice a day. His oxygen saturations are 97%.

Answer A is correct. Smoking cessation is a key aspect of managing anyone with obstructive lung disease (GOLD 2017) and pulmonary rehabilitation has been shown to be effective in all stages of COPD (Spruit et al 2013). Sami is not showing any suggestion of requiring end of life discussions at this stage but they should be factored in at a suitably early stage for advanced planning to occur. Similarly, in the absence of any hypoxia, an assessment for oxygen therapy would not be indicated.

Summary

Obstructive lung disease includes asthma, COPD or may be seen to overlap in some patients. In general, asthma patients need treatment with an ICS and the dose should be kept as low as possible in order to maximise impact whilst minimising side effects. COPD patients require bronchodilation first and foremost with the additional use of an ICS in an ICS/LABA combination for people who have recurrent exacerbations (GOLD category D in the main). Asthma/COPD overlap patients require a pragmatic combination of these approaches – a low dose ICS, increasing as needed to manage asthma symptoms, with the addition of a LABA and/or a LAMA to reduce the symptoms of irreversible airflow obstruction. Careful history taking complemented with objective measurements of lung function will help to identify patients with each condition.

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This website is supported by an unrestricted educational grant from Teva Respiratory

This website is supported by unrestricted educational grant from Teva UK Limited. Teva UK Limited has reviewed the content for factual accuracy. | KOL/11/028(1) Date of preparation December 2015 Editorial control of educational content remains with Education for Health.